20231178 Ver 1_More Info Received_20230926

DWR
State -of Pftnh Oroilna
Departrnent -of EnvirOAMMtal O'Lmaty
Dirslon of W&Mr Re�*qgiF-C" 1110sIon Of Water (Resources
7S4 NCACO2H A233 [gl(t ]h .0243 oXb), .0250 (11)(b]4 0259 I8)(b), A2671111jEL JH07 (ej(2] —8u ferAuth-oriL dan
FORM-' 9A 10.3013
Riparian B offer Awthoirizati on Form
A.
AWica nt Inforn%Aol1
1,
f ect Information
19. Nama of pru-ject:Lie
IG. Mearext municipai4:
1-d. SubdivIalon namo:
Ile- Is the prGject locAled in any of North C' ina's taamy coal oourities'?
If ens, anuiAw. lf'beiaw.
❑ Yes
-PNO
1f_ I!9 ihv project located wlthrn a NC Division aF Co"tal Management Area of
EnwlronmArvtal Conwrn AFC 7
El Yes
No
7.
Owner Inform tlon
2E&. Name Q5 Recafded Deed:
ME��
2b, De&J EkxA an¢ Page No.
2r,- Map Bank arbd a No
(r Ckwe a MPy o{"
feowow YMAO 4W OdrFaTeE
wbm fha Jaf was crea
20, Respoftble Party
far car rvi4na
IJIA-
2&. Str"t addre:
2F. Cam, state, zip:
a
21;. TeleO on-o no.:
2h. Fox no,:
--
21, Email addrov
3.
Applicant InfOrnwitim lit el ffewt from owned
3a- Applicant is;
,4gparrt LJ Clher, sD ;
3b_ Nama
3c, Eluslmss name
mod. Stfeet adcrcaa
3e_ City, sty, zip;
47
a-- Ake -Pl
3f. TeiaphoniN m_
14,
Fax DSO.:
!�h_ Email addre-),,3:
AgenVConiu Itant WGrmaticHn (if applicable)
4a. Nam*,
4b. Business name
lirANO: _
4C, Stwl address:
4d. City, atet:�, zip'
4. Telepnone ro.; = L
4f_ Fax no.:
fig_ Email addr-eee•
FORM; BA 10-2013 Page 1 of 4

B.
Project Infa m Can and Prior Project History
1.
Prop" Wafftificat]on -
1 D, PrOpert}+ edenkiricaton rld_ (tax PIN of parcel ID)' _ # --
�, Site MOrdinate s (iro dedmar deg*e:s); Lattude:
Prapsrty size; aues
2.
Sudaar il'ifoulm
2a. N&YA Df neamsl body -0I water to proposed projaot
Zb. WELter 12w8lity ClasaifiQwhon of nearer mwiviriq water, } -
go_ River basin. -AA -
.3-
Project D*scrioun -�
3a, Describe the exisling oonditiomi on to site and ffm genaral lend Low In the vicinity i?f the project a; Ma tirvta
iF�is c�ppllo8lC+or1: { r 4
3b�, ANwh an i8 Vt x 11 exoerpt from the rnosr recaerit version of the IJS topographic map irrdf=5ng the Iocatia-,
of the site
W Atla& an 8 'I� x 11 exoarpt from the most E4cwt varsign Qf the Published Counlyr MRCS S Survey map
de the romee sile _
3d. List the tataI llma*d blear feint of all emst ng sireams (int-ermittent aina parennlaij r{f.
U. Explain the pur,00sie of tna pr4pod prniecT.
++ ++ #
31- D6wxiibe the WON111 proic-:-t ir, detail, inc rucrmg the type of equipment to be uted_
—&qvxo�
4.
J urisdCadonal Dctermination s
4% HaYff JurisdlcWwl wetland or stream dwbmiinatons
Yes No Ll Unknown
lho Corps or Stale ten rY<qusaled or Dbtwned for IlhiS
prrtn'FBr1CS;
-Oect inctudin all pr 1phasesin the si?
4b. If y85, who dlelinaaled the Jurrisd6utbonal areas'#
AgerRyl ConsUltarrt Co pang:
Name elf knowa�:
lher
4o, If YE*. list the dates Of IM Carps juriedi;tional ftk& ]1irtations or StM WWrminaMns and arc
dOCUMMMabon. ..
` 5-
Project History
58. Havo permits or certirica[iuns heon mques cf or otvtairbad U Yes -SIy UrIILdOw
for this "got in- �n all Ion haaf in the s#?
51?, aF yes, expUin arrd datuiC a000rdIng fie 'help fi3e" inst cAons,
Q.
Pubire Prglo= Piano
$R. Is this a pha�wd pr*ct? Ycs NQ
6bt If des, eucplain, — -
FORM: PAID 2013 Page 2 of 4

C. Proposed Impacts Inwiprttory --
1. Buffer Im"cU
la_ Project F% in which prat-9 tred Neu5�
basin?
Tar-Pemlico
Catawba
❑ Randlatmrr
❑ Jordan
❑ Goose Creek
1 b_ Iildividuafty list all tlurfer impacts be&Dw. It arty impauts require .mitigation, there you MUST 91 acrt Section a 4
t11Is forma.
EIrtfer Impact
Reason for Type of irnpa�#
StrL3sm mr i i ir.
— Buffer
Zone 1
Zcyr'Ifb 2
nimber �-
impact (exempt. Augwa4la:
1liillr lirxl
impSol
ImpaCE
P�rman��l �P�
�Ilowa�a wd
required?
ts�4 f:}
(sy it)
0w Temporary
nniigauan]
B 1 N G T
Cg&gpUce or
Ye& No
gob
82 P 'T
Yet LJ No
63P Lj T
Yes Lj No
EA LJ P T
Lj Yes N
Yes U trip
El Yes U No
Total buffer impacm
r
1 � is ommerrta: �
D. Impact Ars ification and Mli igatkm
1. Avoidance and MI nimizatlan
I.E. Speafi-ally describe measures takialt 10 avoid Qr misnlmize tha I EICte In deoigning pr y
i b. Sup rally describe measures taken ra avoid or mlralmlae through construellon
teeF�nl ue$.
2. Buffer Ni igatlan
2a. VY111 lhle project reuult in an Impact within a protN,ed r1parlan buffer theft
El Yee ANO
nequirn buffer mitigation?
2b. If yes, tlhen identlfy the squm-Ef feet of impact to each Zpne pF the riRerian buffer that r&juiros rnitgaMn and
c2lndele the MUM of f l`bQ2tiW Mquimd in the table hekw.
Zorti
Reason for impact
Total impact
multlpr�ar
Required miiige:ion
e air feet
s uare feet
2oe1B t
3 (2 for Gatar tv)
ftie 2
1 5
Total buffer mltlgatlon
requrrod:
2-c. If IDuffer niNAWri is regvired. Is payment 10 a mirigaricc bank or NC CUS
Lj Yoo
_ proposed?
2d If pis, afloat the Boeptani7e letter from the mitigation b$rix or NC DMS.
2-9- If rro, fien dlsam s what type of m t atQn Is prop d_
i �f• �oenf11B�1Cs'
FOAM: HA I),2013 Page 3 of 4

E. Diffuse Flow Plan
All btiffer impaels and Fr h ground impacts f quim diffL� flow ar other farm Qf
st nmator Veatuvnrt. InCludL% a plan that Fully documents how dl%&E� Plow will be
maintained. If a Lena!-$weader is prop m),J, a#ta1;.h a Level Spraader Supple+nerrt Form-
ff club b� site =natralnisi, a &MP v+ef than a #auol spreader is propo&M, please prowide a
plan fuFstormwater troatmerit as outlined in Chapter 8 of the NC 5tprrn-uateL, ).0P
u EVU5.e flaw
❑ Other 6A+IP
F. Supplementary Information
1. En vilrvnrmntal EkocuFnentaelon
la- Dr3�9 zhe pr*ct irlvahm- an expendlLwa of public (federalfsfiaG Imal) funds or the
L i Yes o
use Of ublic ODdBralVelaii ) lianij
115- If You ans red ems' hn the abowe�, does the prQjW re uIre prepwation of an
EYYFT—FN-c—)
environmental dpoumenl pursuant to the req,jir$menls of the National or Male (North
Carolina) ErMronmenial Pot' Act NEPA/SF-PA 7
1 o. If you nrr&wered 'Yes'to the above, hft lhre document bew finaiized by the le
LJ Yes No
Clearing Hpuee? (If so, atUch a oopy Qf the NEPA or SEPA firwl upprowal lelter,)
mmenas:
�, 1Fiol�Cior1S
2a. is ire ells in Viablion of DWR Wedartd Rules � 15A NCAC 02H-0500), Isalahsd
Yes No
Wedand RF�+Ies (1 SA NCAC 02x .13W). DWR Surface Watar or VVefland Standarfs,
or Ri rian Buff-er Rules 06A NCAC i128 .0200 ?
fib, Is this an after-thQ-fact_perFnit applleatearw?
Yes o
_
2c, tf you an 'd " " to one or bath pf the ague quastions, provi¢-, an explanation of the vzalation[e�1:
ApplicantAger rs Pfir1 d Name ; can UAgenSt's $Ignalure �al�
IA "Llb has ie xe6C oNy r an a.rMflmaGan 10%r fteA the E irant ra pm*deo.I
Send ONE oxnpleta set of thi$ form and aocorrtpan7jilg domments to the fortowingg
FOr ++ftzt"r Trwmgwrtatkm profre, ft sent try
FWAt C11355 AODr0 ViCT the U5 ftl-SmI SgrvrCe_
Aw yr Qhapman
NCIDWR - 401 & Butler Transpo tat!an
Permitting Branch
1-1�17 hail Service Comer
Aa"h, NC 27699 - 1617
For oNother profemmnthy Fast Coss mail m
the 11S Fosta! Servke
Stephanie Gps$
NCI?WR - 401 & Suffer PermiWrg Brandt
1617 Mail SeNioe Center
R31019h, NC 27699 - 1617
For yover►nrnert rMPt$p¢r#Ckrr prvAwrs yen[ by
dehveryservice fUn Fedtlx, efc.).
Amyr Chapman
OR NCDVYR - 401 & EuW ' mftportafion
Permitting 5 mnch
512 N. Salisbury Stmet
Raleigh, NC 27604
Fcw oN ether prrp U {enf by d&very service
W51 Wal etrj
OR Steplhanle Goss
NCDWR - 401 & Buffer Permitting Branch
512 N. Salisbury Street
Raleigh, NC 27604
FORM. 0A 10-2131L� Page 4 of a

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